Updates in College Health: A Review of the Literature

1
Updates in College Health A Review of the
Literature

• ACHA National Conference
• Philadelphia, Pennsylvania
• June, 2010

2
Objectives

• Discuss newly published important research
  studies and their relevance to clinical practice
• Understand common research study designs
• Demonstrate evidence based medicine and its
  application in College Health

3
Team

• Cheryl Flynn, MD, MS, MA
• Interim Medical Director, Syracuse University
• Family Medicine epidemiology family therapy
• David Reitman, MD, MBA
• University Physician, George Washington
  University
• Pediatrics and Adolescent Medicine
• Samuel Seward, MD
• Assistant Vice President, Columbia University
• Internal Medicine and Pediatrics
• Sarah Van Orman, MD
• Executive Director, University of
  Wisconsin-Madison
• Internal Medicine and Pediatrics

4
Process Overview

• Team members conducted literature review of
  studies published during past 24 months
• Key search words
• patient population-adolescent, college student,
  university, young adult
• Avoid redundancy of topics presented in 2008
  2009 Updates

5
Steroids for reducing throat pain

• Hayward et al. Corticosteroids for pain relief in
  sore throat systematic review and meta-analysis.
  BMJ 2009 339 b2976

6
Background and Question

• Sore throat common problem in primary care and
  college health
• Most viral 10 Group A Strep
• SU experience 8.7 of provider visits
• Question Are systemic corticosteroids effective
  in reducing symptoms of sore throat?

7
Study Design

• Systematic review with meta-analysis
• Only included placebo controlled randomized
  controlled trials (RCTs)
• Mathematically combined data where possible
• Performed sensitivity analyses to assess
  robustness of findings

8
Study Methods

• Population
• ambulatory setting only (ED or primary care)
• adults or children with acute tonsillitis/pharyngi
  tis or clinical syndrome of sore throat
• excluded studies of infectious mono,
  post-tonsillectomy or intubation, or
  peri-tonsillar abscess
• Intervention
• systemic corticosteroids vs placebo
• (many concurrently received antibiotics /or
  acetaminophen)

9
Results

• 8 RCTs met inclusion criteria
• Population
• 743 patients, nearly balanced between
  adults/children
• 47 exudative ST 44 Strep positive
• Intervention
• Betamethasone IM, dexamethasone IM or PO,
  prednisone PO
• All doses fairly equivalent 60mg PO prednisone
• Quality of included studies
• High all with adequately concealed allocation

10
Resultsquantitative (meta-analysis)

• Complete pain relief
• At one day RR 3.16 NNT 3.7
• At two days RR 1.65 NNT 3.3
• Mean time to onset pain relief
• Steroid group 6.3 hr earlier (plt0.001)
• Sensitivity analyses found no changes in results
• Adult vs child PO vs IM Strep vs viral
  exudative vs not

11
Results--Qualitative

• Adverse effects (reported in only 1 trial)
• 5 hospitalized for IVF (3 steroid, 2 placebo)
• 3 developed peri-tonsillar abscess (1 steroid, 2
  placebo)
• No difference or trend favoring steroids in
• Time to complete resolution of pain
• Time missed work/school
• Recurrent symptoms

12
Conclusion

• Addition of systemic corticosteroids
  significantly reduces pain in patients with sore
  throat

13
Limitations

• Possible confounding of antibiotic use
• Dont know effect of steroids independent of
  antibiotics
• Relatively small number of RCTs
• Unable to assess publication bias

14
Clinical Bottom Line

• Consider adding steroids in patients with severe
  sore throat in non-mono pharyngitis
• 60mg prednisone PO x 1 dose

15
LBP in Children Adolescents

• Ahlqwist, A et al. Physical therapy treatment of
  back complaints on children and adolescents.
  Spine 2008 33 E721-E727.

16
Background

• LBP is common in college health
• Risk factors
• poor physical conditioning, intense exercise,
  inadequate strength/impaired flexibility, family
  history
• Question
• How does individualized physical therapy compare
  to a self-training program in adolescents with
  lower back pain?

17
Study Methods

• Design
• Randomized controlled trial
• Concealed allocation blinding not possible
• Setting
• Primary care
• Population
• 12-18 y.o., lumbar pain at least 2/10 on pain
  scale
• Excluded those w/serious physical or mental
  disease, or those who had PT in prior month
• N 45 baseline comparison between groups similar

18
Study Design

• Intervention
• Intervention group individualized PT and
  exercise plus self-training (PT 1x/wk, exercises
  2x/wk)
• Control group self-training only 3x/wk
• Duration 12 weeks
• Outcomes
• Measured using validated instruments perceived
  health, disability, pain, flexibility/endurance
• Pre/post within groups
• Compared change scores between groups

19
Results

• Perceived health
• (CHQ-CF)
• Both groups had statistically significant
  improvement in nearly all sub-measures pre/post
• No differences between groups

• Disability (Roland Morris Disability
  Questionnaire)
• Both groups had improvement pre/post
• PT -4.6 Control -2.7
• p 0.016 between groups

20
Results

• Pain (visual analogue scale 0-10)
• Drop in pain scores pre/post
• PT -3.6 Control -3.3
• No difference between groups
• No difference in pain duration or quality of pain

• Flexibility muscle endurance (back saver sit
  and reach)
• Both groups had improvement pre/post
• No differences between groups

21
Conclusions

• Both groups improved on all parameters measured
• Small additional benefit with addition of
  physical therapy
• Perceived health status
• Disability ratings

22
Limitations

• Attribution error
• Improvement of health attributed to time or
  interventions?
• Benefits of PT could be attributed to increased
  medical attention
• Small s
• Lack power to find differences between groups

23
Clinical Bottom Line

• The benefit of PT for adolescents with back pain
  is modest at best
• If available, reasonable addition
• If not, most will improve anyway

24
Contraception and Weight

• Dinger et al. Oral Contraceptive effectiveness
  according to body mass index, weight, age, and
  other factors. Am J Obstet Gynecol 2009 201 263
  e 1-9.
• Chi et al. Early weight gain predicting later
  weight gain among depo medroxyprogesterone
  acetate users. Obst Gynecol 2009 114 279-84

25
OCP effectiveness across BMI

• Research Question
• Are OCPs effective across varying BMIs?
• Design Cohort
• Subset of prospective surveillance study
• Followed 58K women Q6mo x 5 yr
• Contraceptive failure rate was an a priori
  secondary outcome

26
Results

• Population
• 142,475 women years avg duration follow-up 2.4
  years
• Mean age 25.2 mean BMI 22.1 20.4 first time
  OCP users
• Outcomes
• OCP failure rate 0.75 year 1 ? 1.67 year 4
• NO DIFFERENCE in effectiveness across BMI range
• Limitations
• Lower than expected failure rates
• Did not enroll morbidly obese women

27
Predicting weight gain in DMPA users

• Research Question
• Does early weight gain in depo-users predict
  continued excessive weight gain?
• Design Cohort
• 240 women 16-33 y.o. choosing depo followed Q 3-6
  months for 3 yrs
• Depo-users divided into two categories
• Avg (lt5 by 6mo) vs early wt gainers (gt5 by 6mo)
  
• Predictors of excessive gain at 6 mo included
• past pregnancy (RR 2.2), BMIlt30 (RR 4.0)

28
Results
12 mo 24 mo 36 mo
Avg (N144) 0.63 kg 1.48 kg 2.49 kg
Early (N51) 8.04 kg 10.86 kg 11.08 kg

• Adjusting for other factors, early gainers had
  7.03 kg more wt gain at 36mo vs avg group
• Limitations
• Small n stats controlled for confounding
• Some who gained wt at 3 months dropped out

29
Clinical Bottom Lines

• OCPs effectiveness/wt

• Depo/wt gain

• OCPs are equally effective across weight/BMI
  spectrum in women who are not morbidly obese

• Significant weight gain from depo use can be
  predicted within the first two doses

30
Treatment of Irritable Bowel Syndrome (IBS)

• Ford AC, Talley NJ, Spiegel BMR, Foxx-Orenstein
  AE, Schiller L, Quigley EM, Moayyedi, P. Effect
  of fibre, antispasmotics, and peppermint oil in
  the treatment of irritable bowel syndrome
  systemic review and meta-analysis. BMJ, 2008
  337a2313.

31
Background and Question

• Primary care providers frequently treat irritable
  bowel syndrome (IBS)
• Many studies lack sufficient power to demonstrate
  efficacy of treatments
• Conflicting outcomes in various studies
• What effect, if any, do fibre, antispasmodics or
  peppermint oil have on the treatment of IBS
  symptoms?

32
Study Methods

• Meta-Analysis of randomized controlled trials
• Peppermint Oil (4 studies)
• Antispasmodics (22 studies)
• Fiber (12 studies)
• Primary, Secondary and Tertiary care settings
• Population-not specified
• Could not have other GI diagnosis

33
Study Design

• Treatment initiated
• Follow-up 1 wk 60 months
• Needed to report
• Global assessment of cure
• Improvement of symptoms
• 35 studies met criteria

34
Results Peppermint Oil (4 studies, 293
Patients)
35
Results- Antispasmodics (22 studies, 12 drugs,
1778 Patients)
36
Results Fiber (12 Trials, 591 Pts)
37
Conclusions

• Fiber, antispasmodics (e.g. scopolamine) and
  peppermint oil each more effective than placebo
  in treating IBS
• NNTT
• Fiber 11
• Antispasmodics 5
• Peppermint Oil 2.5

38
Clinical Bottom Line

• Of three interventions studied, peppermint oil
  shows the highest promise for efficacy in
  treating IBS

39
Sleep Quality

• Lund H, Reider B, Whiting A, Prichard, J. Sleep
  Patterns and Predictors of Disturbed Sleep in a
  Large Population of College Students. J Adol
  Health 46 (2010) 124-142

40
Background / Question

• Much data exists re consequences of poor sleep
  in children/younger adolescents
• Relatively little data in college age group
• NCHA Data
• 53 reported sleep problems
• 37 sleep had negative impact on academics
• In college population..
• What are the predominant sleep habits?
• Can quality of sleep hygiene predict physical or
  behavioral symptoms?
• What physical, emotional and psychosocial factors
  predict poor sleep quality?

41
Study Methods and Design

• Cross-sectional Online Study
• Setting Midwestern University
• Population
• College students, age 17-24
• 1125 participants
• 27 1st years, 27 Sophomores, 24 Juniors, 20
  Seniors
• 420 male, 705 Female
• Asked to complete 5 validated surveys to rate
• sleep quality, sleepiness, mood, distress, and
  diurnal symptom variability

42
Results Sleep Quality and Quantity

• Mean total sleep time 7.02 hrs
• 25 lt 6.5 hrs
• 29.4 8hrs
• Quality Sleep (PQSI)
• 34 good
• 38 poor
• Sleepiness (Eppworth Sleepiness Scale)
• 25 scored gt10 (significant daytime sleepiness)

43
Results Sleep Quality, Mood, Health

• Poor Quality Sleepers
• Higher levels of weekday stress (plt0.001)
• SUDS 70.7 vs. 49.9
• Self reported negative moods (plt0.001)
• e.g. POMS Depression 10.66 vs. 7.01
• More physical illnesses (plt0.05)
• 12 missed class in a month 3x
• Increased use of Rx, OTCs and recreational drugs
  to stay awake and to fall asleep gt1x/month

44
Results Predictors of Poor Quality Sleep

• Stress
• Stress about school (39)
• Emotional stress (25)
• Excess noise (33)
• Sleeping Partners (7)
• Talking with friends prior to sleep (6)

45
Conclusions

• Epidemic of insufficient and poor-quality sleep
  in college students
• Perceived stress tends to predict poor
• quality/ quantity of sleep
• Consequences of poor quality sleep include higher
  stress, poorer moods, increased physical
  symptoms, missed classes

46
Limitations

• One-time, non-longitudinal survey
• Students were from one university
• Self-report
• No mention of role of ETOH/Drug use

47
Clinical Bottom Line

• Clinicians need to proactively focus on both the
  quality as well as the quantity of sleep in
  patient history
• Poor Quality Sleepers increased risk of mood
  disorders, substance abuse disorders and somatic
  complaints

48
Douching and STIs

• Tsai CS, Shepherd BE, Vermund SH. Does douching
  increase risk for sexually transmitted
  infections? A prospective study in high-risk
  adolescents. Amer J Obstetrics and Gynecology.
  January 2009. 38e1-e8.

49
Douching and STIs

• Question Is there an association between
  douching and Trichomonas, Chlamydia, Gonorrhea
  and Herpes
• Design Observational Prospective (Longitudinal)
  Cohort
• Results
• Assessed time to STI in women who never,
  sometimes, or always douched
• Average age 16.9 yrs. 73 Black. 65 HIV
  infected
• Always douched had a shorter STI-free time than
  those who never douched. (21)
• Commentary/Limitations
• High risk adolescents, slightly younger than
  college age. 2/3 HIV
• Couching independent risk factor for STI
  acquisition
• Clinical bottom line
• Clinicians should counsel female patients about
  potential STI risks with frequent douching

50
Antidepressant Treatment

• Fournier JC, DeRubeis RJ, Hollon SD, Dimidjian S,
  Amsterdam JD, Shelton RC, and J. Fawcett.
  Antidepressant Drug Effects and Depression
  Severity. JAMA. 2010 303(1)47-53.

51
Background and Question

• Most studies for antidepressant effectiveness in
  severely depressed patients
• Majority of patients treated with antidepressants
  have mild to moderate symptoms
• Question What is the relative benefit of
  antidepressant medication vs. placebo across a
  range of depression symptom severity?

52
Study Methods

• Meta-analysis of 6 randomized placebo controlled
  trials
• Setting-outpatient
• Population
• Adults gt age 18 yrs
• 5 Major depression 1 minor depression

53
Study Design

• Intervention
• Treatment Range 6-11weeks
• 434 Antidepressant vs. 284 placebo
• 3 imipramine and 3 paroxetine
• Outcome
• Hamilton Depression Rating Scale (HDRS)
• Mild to moderate lt 18
• Severe 19-22
• Very severe gt 23
• HDRS 3-point difference-clinically significant

54
Results

• Baseline HDRS 10-39
• Threshold for effect initial HDRS gt 25
• Medium effect HDRS gt 25
• Large effect HDRS gt 27
• Drop-out rates 9-34

55
Conclusions

• Antidepressant drug effect varies as function of
  disease severity
• Antidepressant drug effect appears to be
  negligible with mild to moderate depression
• Antidepressant drug effect was large only for
  very severe depression

56
Commentary/Limitations

• Few patients with HDRS scores lt 13
• Considered only acute treatment
• Did not include newer antidepressants
• Increased effectiveness of anti-depressant vs.
  reduced effectiveness of placebo

57
Clinical Bottom Line

• Effect of antidepressant therapy on mild to
• moderate depression unclear

58
Hair Shedding

• Kunz M, Seifert B, and RM Trueb. Seasonality of
  Hair Shedding
• in Healthy Women Complaining of Hair Loss.
  Dermatology.
• 2009219105-110.

59
Hair Shedding

• Question Is hair shedding seasonal?
• Study Design Retrospective Case Study
• Results/Conclusions
• Assessed telogen rates
• 823 women, aged 18-78
• 79 with female pattern hair loss (FPHL)
• Telogen rates showed annual periodicity with peak
  in July and April

60
Hair Shedding

• Commentary
• Most marked in women with FPHL
• Student population may have higher rates of
  telogen effluvium
• Clinical Bottom Line Seasonal variation may be
  important to consider for patient counseling and
  for response to treatment

61
Value of Family History

• Wilson B, Quresh N, Santaguida P, Little J,
  Carroll J, Allanson J, and P Raina. Systematic
  Review Family History in Risk Assessment for
  Common Diseases. Annals of Internal Medicine.
  151(12)878-887.

62
Background

• Family history associated with risk for many
  common diseases
• Knowledge of family history may motivate behavior
  change
• Collecting family history is associated with
  risks and benefits
• Collecting family history requires clinician time
  

63
Questions

• 1 Improved Health
• What is the direct evidence that getting a
  family history will improve health outcomes for
  the patient or family?
• 2 Harm
• What is the direct evidence that getting a
  family history will result in adverse outcomes
  for the patient or family?
• 3 Key Elements
• What are the key elements of a family history in
  a primary care
• setting for the purposes of risk assessment for
  common diseases?
• 4 Accuracy
• What is the accuracy of family history, and
  under what conditions
• does the accuracy vary?

64
Study Methods

• Systematic Review, 1995-2009
• 137studies met criteria
• 69 reviewed
• Unable to perform meta-analysis

65
Results 1 Improved Health

• Studies
• 2 uncontrolled studies, high-study bias
• Outcomes
• No studies with direct health effects
• Increased uptake in breast cancer screening only

66
Results 2-Harm

• Studies
• 1 randomized controlled 2 uncontrolled studies
• 2 generic family history 1 cancer risk
• Outcomes
• 1 study found short-term increase in anxiety,
  gone at 3 months
• No long-term adverse effect found

67
Results 3-Key Elements

• Studies
• 20 longitudinal, 21 cross-sectional studies
• Cancer, coronary heart disease, stroke, diabetes
• 40 definitions of positive history
• Outcomes
• Sensitivity greatest
• Parents or other 1st degree relatives
• Specificity greatest
• Relative identified
• gt 1 relative required
• Age of onset

68
Results 4-Accuracy

• Studies
• Specialized disease clinics
• 23-Longitudinal, Case-control, and Case series
• Patient report vs. relatives medical records
• Outcomes
• Informants disease status did not affect accuracy
• Less accurate for 2nd and 3rd degree relatives
• Widely varying sensitivity and specificity
• Specificity (absence of disease) better than
• sensitivity (presence of history)

69
Conclusions

• No evidence that family history leads to improved
  health
• Insufficient evidence of changed health
  behaviors
• No definitive evidence of lack of harm
• Best method in primary care unclear
• Best for 1st degree relatives
• Accuracy often low, better for absence of disease

70
Commentary/Limitations

• Few well done studies
• Most included patients with the condition of
  interest leading to selection bias
• Many studies not done in primary care settings
• Better studies are needed

71
Clinical Bottom Line

• Family history collection
• is considered to be a
• standard of good care, but
• value is unknown. If
• collected, practitioners
• should focus on 1stdegree
• relatives.

72
Dexamethasone for Migraine

• Singh A, Alter H, Zaia B. Does the Addition of
  Dexamethasone to Standard Therapy for Acute
  Migraine Headache Decrease the Incidence of
  Recurrent Headache for Patients Treated in the
  Emergency Department? A Meta-analysis and
  Systematic Review of the Literature. Acad Emerg
  Med. Dec, 2008.

73
Background and Question

• Migraine is common
• Recurrent migraine after abortive therapy is
  common
• Up to 2/3 patients treated in ED within 48 hours
• Does addition of Decadron to standard therapy
  decrease incidence of recurrent migraine?

74
Study Methods

• Meta-analysis of RCTs
• Inclusion criteria
• Double blind
• Acute Migraine Dx
• Emergency Department (ED)
• Presence of control group
• Adequate follow-up
• 7 studies fulfilled criteria (n742)

75
Study Design

• Intervention standard therapy Decadron (IV
  or PO)
• Outcome moderate or severe migraine at 24 to 72
  hours

76
Results

• Modest but statistically significant benefit to
  adjunctive Rx with Decadron
• ARR 9.7
• RR 0.87
• 95 CI 0.80 to 0.95
• Adverse side effects
• 26 of Decadron pts
• 23 placebo pts

77
Conclusions

• Decadron, in this analysis, shown to decrease
  rate of moderate or severe headache 24-72 hours
  after initial ED Rx

78
Commentary/Limitations

• Standard Treatment defined broadlyand, in some
  studies, arguably unusually
• ED setting
• Not a large n
• Dose and route of Decadron

79
Clinical Bottom Line

• Decadron may have some value in abortive Rx of
  acute migraine

80
X-rays and Harm

• Fazel R, Krumholz H, Yongei Wang SM, et al.
  Exposure to Low-Dose Ionizing Radiation from
  Medical Imaging. NEJM. August, 2009.

81
Background

• Patients, over their lifetimes, are getting
  increasing s of studies with radiation
• Ongoing concern about link between low-dose
  radiation and
• solid tumors
• leukemia
• Patients often unaware of potential risk
• Not all imaging procedures evidence-based

82
Background
Growth in Use of Advanced Imaging under Medicare,
19952005
83
Background
Imaging Procedure Average Effective Radiation Dose
Plain Film 0.01 10 mSv
CT 2 20 mSv
Nuclear 0.3 20 mSv
Interventional 5 70 mSv
84
Study Methods

• Retrospective cohort study
• United Healthcare enrollee records

85
Study Design

• January 1, 2005 to December 31, 2007
• Ages 18 64 yo
• 5 sites
• Arizona, Dallas, Orlando, South Florida,
  Wisconsin
• CPT codes
• Standard definitions of Effective Dosing for
  radiation

86
Results

• 1M total patients
• 68.8 at least one imaging procedure
• 655,613 patients
• Higher in older age groups
• 85.9 of 60-64 years
• 49.5 18-34 years
• Higher by gender
• Women 78.7 and Men 57.9
• Mean 1.2 /- 1.8 procedures/patient/year
• Median 0.7 procedures/patient/year

87
Results
Distribution of Annual Effective Doses of
Radiation Stratified by Gender
88
Conclusions

• Nearly 70 study population underwent 1 imaging
  procedure during 3-year study period
• Gender-specific findings bear further study

89
Commentary/Limitations

• Imagining procedures are a source of radiation
  exposure in the United States
• can result, over time, in high cumulative
  effective doses
• Young people included
• Challenge balancing immediate clinical need
  with LT dose effect
• Selection bias
• Claims data

90
Clinical Bottom Line

• More is being discovered about imaging practices
  in the U.S. and their potential negative relation
  to long-term health effects.
• Primum non nocere

91
Radiologic Work-Up for Acute Abd PainWhat Helps
Nail the Dx?

• Lameris W, van Randen A, van Es HW, et al.
  Imaging strategies for detection of urgent
  conditions in patients with acute abdominal pain
  diagnostic accuracy study. BMJ. March 2009.

92
Background

• Abdominal pain is common
• 5-10 ED visits
• Columbia AY 08-09 830 cases
• CT and U/S have both been shown to
• Positively effect diagnostic accuracy
• Impact management decisions
• Both costly
• CT radiation exposure

93
Question

• What is the optimal imaging strategy for accurate
  diagnosis of urgent conditions related to acute
  abdominal pain?

94
Study Methods

• Prospective, paired diagnostic accuracy study
• 6 academic medical centers
• Adults 18yo with acute non-traumatic abdominal
  pain
• ED setting
• Exclude
• Pregnancy
• Shock
• Ruptured AAA
• Patients for whom no imaging indicated

95
Study Design

• Diagnostic Strategies
• Diagnosis following clinical evaluation (CE)
• CE plain films
• CE U/S
• CE CT
• CE U/S CT (if U/S negative or inconclusive)

96
Results

• 1021 patients
• ED/Urgent Care settings
• Mean age 47 years
• 55 female
• Ethnicity/Race not specified
• 66 of patients hospitalized following ED
  evaluation
• 47 required surgical procedure

97
Results
Final Diagnoses URGENT
Diagnosis No ()
Appendicitis 284 (28)
Cholecystitis 52 (5)
Gynecological 27 (3)
Urological 22 (2)
Pneumonia 11 (1)
Total 661 (65)
98
Results
Final Diagnoses NON-URGENT
Diagnosis No ()
Non-specific Abdominal Pain 183 (18)
IBD 30 (3)
Gynecological 9 (1)
Total 360 (35)
99
Conclusions
Imaging Strategy Sensitivity Specificity False Negatives False Positives
1) Clinical Exam 88 41 12 27
2) CE Plain Films 88 43 12 26
3) CE U/S 70 85 30 11
4) CE CT 89 77 11 12
5) CE U/S /- CT 94 68 6 16

• All values in percentages (95 confidence
  intervals)
• Strategy 5 approximately ½ total number of CTs
• completed in strategy 4

100
Commentary/Limitations

• More than one way to peel a banana
• Stepped approach to w/u may or may not be
  practical depending on patient/sx severity
• And, if time allows, U/S before CT has merits
• Non-randomized
• Most patients referred to EDselection bias

101
Clinical Bottom Line

• As a single imaging strategy, CT is overall
  better than U/S for urgent conditions
• A conditional strategy with CT reserved for
  -/inconclusive U/S provides
• highest sensitivity
• reduced population-based radiation exposure